Guidelines
Clinical management of patients with COVID-19: Second interim guidance

Clinical management of patients with COVID-19: Second interim guidance

Alternative Organization

Screening and Triage

Screening and triage to screen and isolate all patients with suspected COVID-19 at the first point of contact with the health care system (such as the emergency department or outpatient department/clinic). Consider COVID-19 as a possible etiology in patients presenting with acute respiratory illness and place all patients suspected to have COVID-19 under Droplet and Contact Precautions, with the addition of Airborne Precautions if performing any aerosol-generating medical procedures. Triage patients using standardized triage tools and manage initial presentations accordingly.

Infection Prevention and Control

Collection of Specimens for Laboratory Diagnosis

Collect specimens for COVID-19 testing as recommended by your local or provincial public health laboratory.

Collect blood cultures for bacteria where clinically indicated based on the presenting syndrome, for example, sepsis or severe pneumonia, ideally before antimicrobial therapy. Do not delay antimicrobial therapy to collect blood cultures. Blood cultures should be done in children if clinically indicated.

Management of Mild COVID-19

Patients with mild disease do not require hospitalization, unless there is concern for rapid deterioration or an inability to return promptly to hospital.

Isolation is necessary to contain virus transmission. All patients cared for outside hospital should be instructed to follow public health protocols for self-isolation and return to hospital if symptoms worsen. Self-isolation protocols are available from PHAC and provincial/territorial and local public health departments.

Provide patients with mild COVID-19 information on symptomatic treatment.

Counsel patients with mild COVID-19 and their caregivers about the signs and symptoms of complications that should prompt urgent care. If they develop symptoms like difficulty breathing, pain or pressure in the chest, confusion, drowsiness, or weakness, they should seek follow-up care.

Antibiotics should not be prescribed to patients with suspected or confirmed mild COVID-19 unless there is clinical suspicion of a bacterial infection.

Management of Severe COVID-19

Give supplemental oxygen therapy immediately to patients with COVID-19 who have severe acute respiratory infection and respiratory distress, hypoxaemia or shock, and target saturations of 90-96% SpO2 during resuscitation.

Closely monitor patients with COVID-19 for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis and respond immediately with supportive care interventions.

Understand the patient’s co-morbid conditions and tailor management accordingly.

Use conservative fluid management in patients with severe acute respiratory infection when there is no evidence of shock.

Give empiric antimicrobials to treat all likely pathogens causing severe acute respiratory infection and sepsis as soon as possible, within 1 hour of initial patient assessment for patients with sepsis.

Frequently re-evaluate and de-escalate empiric therapy where possible on the basis of microbiology results and clinical judgment.

Management of Critical COVID-19

Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy and prepare to provide advanced oxygen/ventilatory support.

Endotracheal intubation should be performed by a trained and experienced provider using airborne precautions.

Among hospitalized adult patients who have COVID-19 and require supplemental oxygen or mechanical ventilation, clinicians should strongly consider dexamethasone 6 mg IV daily for 10 days (or until off oxygen or discharge if earlier) or equivalent glucocorticoid dose.

Implement mechanical ventilation using lower tidal volumes (4–8 mL/kg predicted body weight [PBW]) and lower inspiratory pressures (plateau pressure < 30 cmH2O).

In adult patients with severe ARDS, prone ventilation for 12- 16 hours per day should be considered.

Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion.

In patients with moderate or severe ARDS, higher PEEP instead of lower PEEP is suggested.

In patients with moderate-severe ARDS (PaO2/FiO2 < 150), neuromuscular blockade by continuous infusion should not be routinely used.

Avoid disconnecting the patient from the ventilator, which results in loss of PEEP and atelectasis.

Use in-line catheters for airway suctioning and clamp the endotracheal tube when disconnection is required (e.g., transfer to a transport ventilator).

High-flow nasal oxygen (HFNO) and non-invasive ventilation (NIV) should be considered. Patients treated with either HFNO or NIV should be closely monitored for clinical deterioration.

In settings with access to expertise in extracorporeal membrane oxygenation (ECMO), consider referral of patients who have refractory hypoxemia despite lung protective ventilation.

Recognize septic shock in adults when infection is suspected or confirmed AND vasopressors are needed to maintain mean arterial pressure (MAP) ≥ 60 mmHg AND lactate is ≥ 2 mmol/L, in absence of hypovolemia.

Recognize septic shock in children with any hypotension (systolic blood pressure [SBP] < 5th centile or 2 SD below normal for age) or two or more of the following: altered mental state; bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and HR < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or feeble pulses; tachypnea; mottled or cool skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia.

In resuscitation for septic shock in adults, give 250-500 mL crystalloid fluid as a rapid bolus in the first 15- 30 minutes and reassess for signs of fluid overload after each bolus.

In resuscitation for septic shock in children, give 10-20 mL/kg crystalloid fluid as a rapid bolus in the first 30-60 minutes and reassess for signs of fluid overload after each bolus.

Fluid resuscitation may lead to volume overload, including respiratory failure, particularly with ARDS. If there is no response to fluid loading or signs of volume overload appear (e.g. jugular venous distension, crackles on lung auscultation, pulmonary edema on imaging, or hepatomegaly in children), then reduce or discontinue fluid administration. This step is particularly important in patients with hypoxemic respiratory failure.

Do not use hypotonic crystalloids, starches or gelatins for resuscitation.

In adults, administer vasopressors when shock persists during or after fluid resuscitation. The initial blood pressure target is MAP ≥ 60 mmHg in adults and improvement of markers of perfusion.

In children administer vasopressors if signs of fluid overload are apparent or the following persist after two fluid boluses: there are signs of shock such as altered mental state; tachycardia or bradycardia (HR < 90 bpm or > 160 bpm in infants and HR < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 seconds) or feeble pulses; tachypnea; mottled cool skin or petechial or purpuric rash; increased lactate; persisting oliguria; or age-appropriate blood pressure targets are not achieved

If central venous catheters are not available, vasopressors can be given through a peripheral IV, but use a large vein and monitor closely for signs of extravasation and local tissue necrosis. If extravasation occurs, stop the infusion. Vasopressors can also be administered through intraosseous needles.

If signs of poor perfusion and cardiac dysfunction persist despite achieving the MAP target with fluids and vasopressors, consider an inotrope such as dobutamine.

Special Considerations

Pregnant and recently pregnant women with suspected or confirmed COVID-19 should be treated with the supportive and management therapies previously described for other adults, taking into account the immunologic and physiologic adaptations occurring during and after pregnancy.

Pregnant women with a suspected, probable or confirmed COVID-19 infection, including women who may need to spend time in isolation, should have access to woman-centred, respectful skilled care, including obstetric, foetal medicine and neonatal care, as well as mental health and psychosocial support, with readiness to care for maternal and neonatal complications.

All recently pregnant women with COVID-19 infection or who have recovered from COVID-19 should be provided with counselling on safe infant feeding and appropriate infection prevention measures to prevent COVID-19 transmission.

Pregnant and recently pregnant women who have recovered from COVID-19 should be encouraged to attend enhanced antenatal, postpartum or other obstetrical care as appropriate. Enhanced fetal surveillance is recommended for women with COVID-19 illness.

Infants born to mothers with suspected, probable, or confirmed COVID-19 should be fed according to standard infant feeding guidelines, primarily breast feeding while providing necessary infection prevention precautions.

Symptomatic mothers who are breastfeeding should practice respiratory hygiene, including during feeding (for example, use of a mask when near a child if the mother has respiratory symptoms), perform hand hygiene before and after contact with the child, and routinely clean and disinfect surfaces with which the symptomatic mother has been in contact.

In situations when severe illness in a mother due to COVID-19 or other complications prevents her from caring for her infant or prevents her from continuing direct breastfeeding, mothers should be encouraged and supported to express milk, and safely provide breast milk to the infant, while applying appropriate IPC measures.

Mothers and infants should be allowed to remain together and to practice rooming-in if desired, especially during establishment of breastfeeding, whether they or their infants have suspected, probable or confirmed COVID-19.

Parents and caregivers who may need to be separated from their children, and children who may need to be separated from their primary caregivers, should have access to appropriately trained health or non-health workers for mental health and psychosocial support.

Identify if there is an advance care plan for patients with COVID-19 and ensure the care plan takes into consideration their priorities and preferences. Tailor the care plan to be in line with the patient’s expressed wishes.

For older persons with probable or suspected COVID-19, in addition to a conventional history the assessment should include an understanding of the person’s life, values, priorities and preferences for health management.

Ensure multidisciplinary collaboration (physicians, nurses, pharmacists and other health professionals) in the decision-making process to address multimorbidity and functional decline.

Early detection of inappropriate medication prescriptions is recommended to prevent adverse drug events and drug interactions in those being treated for COVID-19.

Where appropriate, involve caregivers and family members in decision-making and goal setting throughout the management of older COVID-19 patients.

Symptom-based and palliative care should be provided, as appropriate, even for patients with supportive or curative goals of care.

Primary care providers or nursing stations, where available, should plan to provide triage and assessment, primary care treatment and monitoring.

Mild disease, including uncomplicated pneumonia, should be managed within the community, with appropriate precautions in place.

Alternate arrangements for self-isolation may be needed for persons in crowded living arrangements.

Fluid management should be conservative when there is no evidence of shock, because aggressive fluid management may worsen oxygenation in settings without access to mechanical ventilation.

Mild cases may progress to lower respiratory tract disease. Possible risk factors for progression to severe illness include older age and underlying chronic medical conditions such as lung disease, cancer, heart failure, cerebrovascular disease, renal disease, liver disease, diabetes, immunocompromising conditions, and pregnancy.

Patients should be carefully monitored for signs of impending deterioration so that transfer can be arranged before intubation is required.

Anticipate delays to access hospital care (awaiting air-ambulance, weather issues). Therefore, a low threshold should be considered for medevac options, particularly for the elderly, persons with underlying medical conditions or persons with evidence of pneumonia.

Specific and Adjunctive COVID-19 Treatments and Clinical Research

Collect standardized clinical data on all hospitalized patients to improve our understanding of the natural history of disease.

Among hospitalized adult patients who have COVID-19 and require supplemental oxygen or mechanical ventilation, clinicians should strongly consider dexamethasone 6 mg IV daily for 10 days (or until discharge if earlier) or equivalent glucocorticoid dose.

Consider the use of Remdesivir, either as a therapy or preferably as part of a randomized controlled trial.

Do not use hydroxychloroquine or ritonavir/lopinavir outside of a clinical trial.

Use of investigational anti-COVID-19 therapeutics should be done under ethically approved, randomized, controlled trials.

Management of Moderate COVID-19

Patients with moderate suspected or confirmed COVID-19 (for example, with clinical signs of pneumonia but no signs of severe pneumonia, including SpO2 ≥ 90% on room air) who are not determined to be at high risk of deterioration may not require hospitalization, but they should be isolated.

Antibiotics should not be prescribed to patients with suspected or confirmed moderate COVID-19 unless there is clinical suspicion of a bacterial infection.

Palliative Care and COVID-19

We recommend identifying, in all patients with COVID-19, if they have an advance care plan for COVID-19 (such as desires for intensive care support) and to discuss goals of care in the setting of acute illness. Patient priorities and preferences should be respected and their care plan tailored to allow the provision of the best care irrespective of treatment choice.

Palliative care services should be made accessible at each institution that provides care for persons with COVID-19, and symptomatic treatments (for example, management of dyspnea) should be provided even for patients with supportive or curative goals of care.

Immunocompromised Patients and COVID-19

Patients living with HIV Infection should be offered standard of care.

In solid organ transplant patients, the risk of COVID 19 infection from a living donor or deceased donor is unknown at this time and such decisions on transplantation are to be made with expert advice.

In Hematopoietic Stem Cell Transplantation (HSCT) patients, it is recommended that all recipients should have a negative COVID 19 PCR test prior to start of conditioning.